Overview of acute arterial occlusion of the extremities (acute limb ischemia)
- Marc E Mitchell, MD
Marc E Mitchell, MD
- Associate Professor of Surgery
- University of Mississippi School of Medicine
- Jeffrey P Carpenter, MD
Jeffrey P Carpenter, MD
- Professor and Chairman
- Department of Surgery
- Cooper Medical School of Rowan University, Camden, NJ
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- Emile R Mohler III, MD
Emile R Mohler III, MD
- Section Editor — Vascular Medicine
- Professor of Medicine
- University of Pennsylvania School of Medicine
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
INTRODUCTION AND DEFINITIONS
According to the 2007 Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II), acute limb ischemia is defined as a sudden decrease in limb perfusion that causes a potential threat to limb viability (manifested by ischemic rest pain, ischemic ulcers, and/or gangrene) . Patients who present later than two weeks after the onset of the acute event are considered to have chronic limb ischemia.
The management of acute arterial occlusion remains a challenge for vascular specialists. Surgical thromboembolectomy and bypass grafting were the mainstays of therapy for many years . Subsequently, thrombolytic therapy and percutaneous transluminal angioplasty (PTA) have become treatment options for selected patients [3,4].
Despite these advances, the morbidity, mortality, and limb loss rates from acute lower extremity ischemia remain high . Thus, regardless of the treatment modality used, early diagnosis and rapid initiation of therapy are essential in order to salvage the ischemic extremity.
The major causes of, and management approaches to, acute limb ischemia will be reviewed here. Issues related to chronic limb ischemia (ie, similar manifestations in patients who present more than two weeks after symptom onset) are discussed separately. (See "Treatment of chronic lower extremity critical limb ischemia".)
Acute arterial occlusion can be the result of an embolus from a proximal source lodging into a more distal vessel, acute thrombosis of a previously patent artery, acute thrombosis of a stent or graft, and dissection of an artery or direct trauma to an artery. Common etiologies for each of these mechanisms are presented in the table (table 1).
- Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S:S5.
- Yeager RA, Moneta GL, Taylor LM Jr, et al. Surgical management of severe acute lower extremity ischemia. J Vasc Surg 1992; 15:385.
- Kashyap VS, Gilani R, Bena JF, et al. Endovascular therapy for acute limb ischemia. J Vasc Surg 2011; 53:340.
- Hynes BG, Margey RJ, Ruggiero N 2nd, et al. Endovascular management of acute limb ischemia. Ann Vasc Surg 2012; 26:110.
- Baril DT, Patel VI, Judelson DR, et al. Outcomes of lower extremity bypass performed for acute limb ischemia. J Vasc Surg 2013; 58:949.
- Skeik N, Soo-Hoo SS, Porten BR, et al. Arterial Embolisms and Thrombosis in Upper Extremity Ischemia. Vasc Endovascular Surg 2015; 49:100.
- Clagett GP, Sobel M, Jackson MR, et al. Antithrombotic therapy in peripheral arterial occlusive disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:609S.
- Abbott WM, Maloney RD, McCabe CC, et al. Arterial embolism: a 44 year perspective. Am J Surg 1982; 143:460.
- Miller S, Causey MW, Schachter D, et al. A case of limb ischemia secondary to paradoxical embolism. Vasc Endovascular Surg 2010; 44:604.
- Dao CN, Tobis JM. PFO and paradoxical embolism producing events other than stroke. Catheter Cardiovasc Interv 2011; 77:903.
- Bleda Moreno S, De Haro Miralles J, Flórez González A, Acín García F. [Relationship between lower limb deep vein thrombosis and acute pulmonary and ischaemic upper limb thromboembolism: a case of a paradoxical embolism]. Cir Esp 2010; 88:342.
- Hugl B, Klein-Weigel P, Posch L, et al. Peripheral ischemia caused by paradoxical embolization: an underestimated problem? Mt Sinai J Med 2005; 72:200.
- Travis JA, Fuller SB, Ligush J Jr, et al. Diagnosis and treatment of paradoxical embolus. J Vasc Surg 2001; 34:860.
- Herity NA, Dalzell GW. Venous thrombosis causing arterial embolization to the same limb through a patent foramen ovale. Clin Cardiol 1997; 20:893.
- Paes EH, Greven T, Heredia D. Paradoxical embolism and aortic occlusion: a case report. Int Angiol 1997; 16:72.
- AbuRahma AF, Downham L. The role of paradoxical arterial emboli of the extremities. Am J Surg 1996; 172:214.
- Nasser TK, Mohler ER 3rd, Wilensky RL, Hathaway DR. Peripheral vascular complications following coronary interventional procedures. Clin Cardiol 1995; 18:609.
- Messina LM, Brothers TE, Wakefield TW, et al. Clinical characteristics and surgical management of vascular complications in patients undergoing cardiac catheterization: interventional versus diagnostic procedures. J Vasc Surg 1991; 13:593.
- Creager MA, Kaufman JA, Conte MS. Clinical practice. Acute limb ischemia. N Engl J Med 2012; 366:2198.
- Karmody AM, Powers SR, Monaco VJ, Leather RP. "Blue toe" syndrome. An indication for limb salvage surgery. Arch Surg 1976; 111:1263.
- Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997; 26:517.
- Katzen BT. Clinical diagnosis and prognosis of acute limb ischemia. Rev Cardiovasc Med 2002; 3 Suppl 2:S2.
- Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463.
- Alonso-Coello P, Bellmunt S, McGorrian C, et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e669S.
- Riggs P, Ouriel K. Thrombolysis in the treatment of lower extremity occlusive disease. Surg Clin North Am 1995; 75:633.
- Huettl EA, Soulen MC. Thrombolysis of lower extremity embolic occlusions: a study of the results of the STAR Registry. Radiology 1995; 197:141.
- Berridge DC, Kessel DO, Robertson I. Surgery versus thrombolysis for initial management of acute limb ischaemia. Cochrane Database Syst Rev 2013; 6:CD002784.
- Carpenter JP, Barker CF, Roberts B, et al. Popliteal artery aneurysms: current management and outcome. J Vasc Surg 1994; 19:65.
- Ouriel K, Veith FJ, Sasahara AA. Thrombolysis or peripheral arterial surgery: phase I results. TOPAS Investigators. J Vasc Surg 1996; 23:64.
- Ouriel K, Veith FJ, Sasahara AA. A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. Thrombolysis or Peripheral Arterial Surgery (TOPAS) Investigators. N Engl J Med 1998; 338:1105.
- Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity. The STILE trial. Ann Surg 1994; 220:251.
- Weaver FA, Comerota AJ, Youngblood M, et al. Surgical revascularization versus thrombolysis for nonembolic lower extremity native artery occlusions: results of a prospective randomized trial. The STILE Investigators. Surgery versus Thrombolysis for Ischemia of the Lower Extremity. J Vasc Surg 1996; 24:513.
- Ouriel K, Shortell CK, DeWeese JA, et al. A comparison of thrombolytic therapy with operative revascularization in the initial treatment of acute peripheral arterial ischemia. J Vasc Surg 1994; 19:1021.
- Kessel DO, Berridge DC, Robertson I. Infusion techniques for peripheral arterial thrombolysis. Cochrane Database Syst Rev 2004; :CD000985.
- Robertson I, Kessel DO, Berridge DC. Fibrinolytic agents for peripheral arterial occlusion. Cochrane Database Syst Rev 2013; 12:CD001099.
- Berridge DC, Gregson RH, Hopkinson BR, Makin GS. Randomized trial of intra-arterial recombinant tissue plasminogen activator, intravenous recombinant tissue plasminogen activator and intra-arterial streptokinase in peripheral arterial thrombolysis. Br J Surg 1991; 78:988.
- Mahler F, Schneider E, Hess H, Steering Committe, Study on Local Thrombolysis. Recombinant tissue plasminogen activator versus urokinase for local thrombolysis of femoropopliteal occlusions: a prospective, randomized multicenter trial. J Endovasc Ther 2001; 8:638.
- Meyerovitz MF, Goldhaber SZ, Reagan K, et al. Recombinant tissue-type plasminogen activator versus urokinase in peripheral arterial and graft occlusions: a randomized trial. Radiology 1990; 175:75.
- Ouriel K, Kandarpa K, Schuerr DM, et al. Prourokinase versus urokinase for recanalization of peripheral occlusions, safety and efficacy: the PURPOSE trial. J Vasc Interv Radiol 1999; 10:1083.
- Schweizer J, Altmann E, Stösslein F, et al. Comparison of tissue plasminogen activator and urokinase in the local infiltration thrombolysis of peripheral arterial occlusions. Eur J Radiol 1996; 22:129.
- Eliason JL, Wainess RM, Proctor MC, et al. A national and single institutional experience in the contemporary treatment of acute lower extremity ischemia. Ann Surg 2003; 238:382.
- Earnshaw JJ, Whitman B, Foy C. National Audit of Thrombolysis for Acute Leg Ischemia (NATALI): clinical factors associated with early outcome. J Vasc Surg 2004; 39:1018.
- Duval S, Keo HH, Oldenburg NC, et al. The impact of prolonged lower limb ischemia on amputation, mortality, and functional status: the FRIENDS registry. Am Heart J 2014; 168:577.
- INTRODUCTION AND DEFINITIONS
- Arterial emboli
- Paradoxical embolism
- Arterial thrombosis
- Arterial trauma
- EPIDEMIOLOGY AND RISK FACTORS
- Risk factors
- CLINICAL PRESENTATIONS
- Without underlying vascular disease
- With occlusive vascular disease
- PHYSICAL EXAMINATION
- Six P’s
- Blue toe syndrome
- Clinical categories of ischemia
- Vascular imaging
- DIFFERENTIAL DIAGNOSIS
- INITIAL MANAGEMENT
- Medical risk assessment
- MANAGEMENT BY SEVERITY OF ISCHEMIA
- Viable extremity
- - Thrombolytic therapy versus surgery
- - Recommendations of others
- Threatened extremity
- Nonviable extremity
- MORBIDITY AND MORTALITY
- SUMMARY AND RECOMMENDATIONS